Application for Employment
This application form will be used by the Thames-Coromandel District Council
to assist in considering your application. If you are successful, this information
will become part of your personnel records.
Instructions
To make it easy we have enabled this form to be completed electronically.
Remember to save and email your completed application documentation to
[email protected]
1.
Position Details
Position Applied For:
2.
Personal Details
Name:
Contact Address:
Contact Phone (day):
Email Address:
3.
Legal Work Status
NZ Citizen
4.
NZ Resident
Work Visa
Education and Training
Provider
Qualification
Year Attained
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Application for Employment
5.
Medical Details
Declaration of your medical details and criminal convictions will be kept
confidential and will not necessarily discount you from consideration for this
position.
Do you have any current health or physical matters which Yes
are relevant to this positions and/or impairment which may No
be aggravated by activities in this position, (eg back,
hearing, eyesight or heart problems, or any physical injury?)
If 'yes' please provide details below
Have you had an injury or medical
gradual process such as disease
example; hearing loss, sensitivity to
strain injuries that may be aggravated
to by activities in this position?
condition caused by Yes
or infection?
For No
chemicals, repetitive
or further contributed
If 'yes' please provide details below
Please note:
Thames-Coromandel District Council may need you to undergo a medical
examination by a registered practitioner, who will provide a confidential report
to Council on your state of health. This examination and report will be at the
Council's expense.
6.
Criminal Convictions
Are you awaiting the hearing of charges in a civil or criminal Yes
court of law?
No
If 'yes' please provide details below.
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Application for Employment
Do you have any civil or criminal convictions, not including Yes
any concealed under the Criminal Records (Clean Slate ) No
Act
If 'yes' please provide details below.
7.
Referees
Name of Referee 1:
Organisation:
Contact Details:
Relationship to you:
Name of Referee 2:
Organisation:
Contact Details:
Relationship to you:
Name of Referee 3:
Organisation:
Contact Details:
Relationship to you:
8.
Advertisement
Please advise where you first saw this advertisement. This is helpful to us for
future advertising and recruitment.
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Application for Employment
9.
Declaration
I consent to Thames-Coromandel District Council seeking verbal or
written information on a confidential basis about me from the
referees I have listed and I authorise the information sought, to be
release by the referees to the Thames-Coromandel District Council Yes
for the purposes of ascertaining my suitability for this position.
I also understand that any false information given in relation to my
medical history with regards to gradual process, disease or Yes
infection, can results in my loss of entitlement for any compensation.
I also declare that, to the best of my knowledge, the details given in
this application are correct and I understand that, if any false or Yes
deliberately misleading information is given, or any material fact
suppressed, I will not be accepted or, if I am employed, my
employment will be terminated.
Signed:
Date:
Check List
Before you send us your application please make sure you have submitted
the following:
 Complete Application for Employment form
 CV
 Competency self-assessment form
How to contact us
07 868 0200 (New Zealand only)
+64 7 868 0200
[email protected]
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